"Should I get proton therapy?" is a question that my patients often ask me, and you may be thinking about it right now. The short answer is that "it depends." Only you and your oncologist should be making this decision.

Before deciding IF you should receive proton therapy, you need to know WHAT it is. Proton Therapy Center at M. D. Anderson, we often need to use many different beams to cover the tumor and this can result in more radiation exposure to normal tissues. This is where proton therapy has the edge. Protons deposit most of their dose at the tumor and, more importantly, stop traveling after they hit the tumor. This reduces the radiation dose beyond the tumor, allows the use of fewer beams and provides greater sparing of normal tissue.

Proton treatment requires sophisticated machinery and expert professionals to deliver it. The synchrotron will accelerate protons to almost the speed of light for maximal penetration. Inside the synchrotron they may travel 300,000 miles, which is equivalent to circling the earth 12-13 times. The protons are then fed to the treatment gantry, which is a massive 190-ton device that directs the proton beam before it enters the patient. Despite its large size (over 40 feet in diameter), the gantries have a precision of 1mm. We also have a highly trained, dedicated group of professionals who operate and maintain the Proton Therapy Center to ensure that everything works to its best level.

Proton therapy is currently available in only seven centers in North America. M. D. Anderson has one of the largest and technically advanced centers in the world. We have four treatment rooms, including one of the only centers with spot-scanning (a.k.a. pencil-beam scanning) capabilities.

The first patient was treated with proton therapy at M. D. Anderson on May 4, 2006, and since then we have treated more than 1,700 patients. We have a lot of experience treating patients with lung cancer, esophageal cancer, brain tumors and prostate cancer, as well as various other tumor sites. Also, we're one of the most active centers in the world for treating children with proton therapy.

Since the Proton Therapy Center is part of M. D. Anderson Cancer Center, we can provide our patients not only with outstanding proton therapy but also outstanding cancer therapy.

So, should you receive proton therapy? Please consult with your radiation oncologist or check out our website for more information.

One small step for proton centers, one giant leap for radiation therapy

Protons have been in use in medicine for nigh on 50 years, but modern proton therapy can hardly be considered mainstream. Many in the field of radiology oncology consider proton therapy to be one of the most advanced medical treatments available, but providing access is no easy matter. Opening a major proton center involves laying down more than $100 million in construction costs and a technological investment that takes up a city block and many tons of concrete to support it. It is no wonder that there are only seven proton centers in operation in the United States, but that number is projected to grow steadily in a matter of a few years. Several more large-scale centers are set to open their doors within five years' time, and an increasing number of lower-cost and smaller-scale proton therapy technologies are preparing for launch, which might alter the trajectory of this very high-tech industry.

Proton therapy is similar in concept to any other form of external beam radiation therapy-the idea is still to target and kill tumor cells by disrupting their haywire DNA, but proton beams have properties that make them ideal for cancer therapy. In short, more of the radiation dose is delivered to the targeted site, thereby sparing more of the healthy tissue that would otherwise be down for the count with conventional radiation therapies using X-ray technology.

There is also less concern about patients developing secondary cancers as a result of radiation treatment. With better so-called dose conformity, oncologists could even seek to increase the dose to provide stronger, more effective proton therapy in fewer treatments. The only real drawback is the cost of building and maintaining one of these centers, which filters into treatment cost and the overall cost of cancer treatment.

Picturing proton therapy

To get a glimpse of proton therapy technology in action, DOTmed visited M.D. Anderson's Proton Therapy Center in Houston and took a tour of the facility with medical director Dr. Andrew Lee. One gantry is set up with state-of-the-art pencil-beam scanning capabilities and an eye chair. Other treatment rooms house a fixed beam line and an experimental beam line, and accompanying all of this is a dedicated machine shop set-up to create plastic compensators and brass apertures that custom sculpt the beam and the subsequent radiation dose for each patient. At full capacity, M.D. Anderson's center can treat 3,500 patients annually and employs about 85 physicians, physicists, dosimetrists, technologists and other staff.

The M.D. Anderson Center uses a synchrotron instead of a cyclotron to accelerate the proton particles in preparation for therapy. The synchrotron produces discrete energies, whereas cyclotrons put out a high-energy beam that is then degraded if a lower-energy beam is needed for treatment.

It all starts with a tank of hydrogen about the size of a fire extinguisher, which is then oscillated. The protons that split off are then accelerated to about two-thirds the speed of light inside the synchrotron. By the end of acceleration, the particles have traveled enough distance to equal 12 or 13 flights in orbit around the earth's equator. The beam is then directed to one of the treatment rooms, three of which house the massive 360-degree rotating gantries that run 13 meters in diameter and weigh about 190 tons, or, as Dr. Lee explains, the weight of a jet airliner without passengers. Standing behind the scenes on a narrow catwalk overlooking a massive, two-story masterpiece of engineering surrounded by miles of wires as it rotates to sub-millimeter precision, it is easy to see what all the excitement is about. For the people involved, the concern is not so much about the cost, but the exploration of the technology and developing the best possible cancer treatment for patients. One aspect somewhat hobbling the technology is the paucity of clinical studies conducted to confirm proton therapy's superiority over conventional X-ray therapy, and results to some studies have been unclear on this point.

Is it really better?

With that said, it should be noted that a recent study conducted by Harvard Medical School and Massachusetts General Hospital in Boston found a 50 percent drop in secondary cancers for patients who were treated with proton therapy compared with X-ray therapy. Other studies have shown definitive advantages in treatment for pediatric and ocular cancers and chordomas at the base of the skull.

Applications for lung cancer are also at the cutting edge of proton therapy. The M.D. Anderson Proton Therapy Center is renowned for its treatment of lung cancer. Proton therapy's benefit over conventional radiation therapy for prostate cancer has not yet been proven, but some in the industry swear that proton therapy means fewer complications and secondary malignancies, making it an important choice in prostate cancer treatment planning.

Protons for pediatrics

Perhaps the greatest application for proton therapy is in pediatric medicine, a field hyper-sensitive to the issue of radiation dose and the after-effects of treatment.

"For kids, one of the things about radiation therapy is that even low doses can have pretty profound effects later in life," says Dr. Lee. "That can be as obvious as cosmetic defects, because if bone is exposed to a certain dose of radiation in a growing child, it's not going to grow at the same rate as bone that isn't exposed. It could be something in between, like cognitive defects - maybe they have a little bit of trouble paying attention in school. It could be something really subtle."

ScienceDaily (June 1, 2010) — TU Delft and Molecular Imaging Labs (MI Labs) have succeeded in combining two forms of medical imaging techniques into one piece of equipment. These techniques are particularly useful for cancer research. The two techniques are known as microPET and microSPECT. SPECT and PET can be performed simultaneously and they give a higher resolution than traditional microSPECT and microPET.

The new device is known as the VECTor (Versatile Emission Computed Tomography) and is designed for use in fundamental research into the functioning of cells and organs. It can show functional details smaller than half a millimetre.

Cancer research

Positron Emission Tomography (PET) and Single Photon Emission Computed Tomography (SPECT) are used in cancer research and diagnosis, among other things. PET and SPECT are also commonly used to carry out fundamental research into living cells and disease mechanisms or to develop better methods of diagnosis and treatment. The equipment that has now been developed at TU Delft and MI Labs is designed for fundamental research using experimental animal models. The combined PET/SPECT apparatus offers extremely high resolution, reduces use of laboratory animals and also offers financial savings when carrying out research in this area. Previously, both types of equipment would have had to be bought separately and less information could be gained from each individual animal.

Unprecedented precision

Prof. Freek Beekman, professor at TU Delft and CEO/CSO of MI Labs, previously was in charge of developing the U-SPECT, one of the two elements in the new combined apparatus. This U-SPECT (Ultra-high resolution Single Photon Emission Computed Tomographer) is much more precise than the normal SPECT apparatus or other scanning techniques.

'These scanners allow us to see how cells and organs function in unprecedented detail. There are already more than ten U-SPECTs around the globe, which can test new tracers and pharmaceuticals for cancer, cardiac problems and brain diseases,' says Beekman.

Early detection

The U-SPECT, and later the combined U-SPECT/PET scanner, is currently being used for research using mice. 'The challenge is now to build a U-SPECT that can be used on people, so that tumours can be detected and classified early, for example, and the right treatment can be started immediately,' says Beekman.

Medical Delta

The further development of U-SPECT is part of the worldwide quest for more efficient medical imaging technology, radiotherapy and tumour seekers. These efforts are slowly but surely leading to ever better cancer treatments, according to Beekman. We still have much to gain by improving technology for detecting and treating cancer. Beekman emphasises that it is important for hospitals and technicians to work together very closely.

TU Delft and MILabs are taking action in this area by participating in Medical Delta. They are cooperating with Erasmus University, the University of Leiden and their two affiliated academic hospitals.

Scripps Health and Scripps Clinic Medical Group are allowing their name and their doctors to help build a $185 million proton beam center for cancer therapy, a for-profit venture in San Diego that could be the ninth accelerator in the nation when it opens in 2013, and the second in the Western United States.

The Scripps Proton Therapy Center will be financed and owned by Advanced Particle Therapy (APT) LLC of Minden, NV, but will be managed by Scripps Clinic physicians. The 102,000-square-foot center will be built starting next month about 5 miles east of the Scripps campus. When complete, it will have the capacity to treat 2,400 patients a year for cancers of the prostate, pancreas, lung, head and neck, breast, colon, eye, and digestive system. The only other such center in the West, at Loma Linda University, was the first in the U.S. in 1990.

The proton beam approach delivers radiation more directly to the tumor site and avoids collateral damage to surrounding cells and tissue, says Prabhakar Tripuraneni, MD, head of radiation oncology at Scripps Green Hospital in La Jolla.

That collateral damage is believed responsible for secondary tumors that often occur after more generalized doses of radiation treatments. He said proton beam is increasingly used for deep-seated but localized tumors—those that have not spread—that are difficult to remove surgically, including ocular and lung cancers.

Proton beam radiation treatment is perhaps the least well known of radiation cancer strategies, because there are only seven such installations centers in the country. Also, at about $45,000 for a course of treatments, it is perhaps the most expensive radiation therapy offered today.

The center will be equipped by Varian Medical Systems of Palo Alto, Varian's first proton beam installation in the U.S.

While the center plans to accept patients from all health systems in the region, clearly attaching the name Scripps to the center will bring the five-hospital healthcare system prestige and stature, several proton beam experts note.

- Francis H. Burr Proton Center at Massachusetts General Hospital in Boston
- Roberts Proton Therapy Center at the University of Pennsylvania in Philadelphia
- ProCure Proton Therapy Center at the INTEGRIS Cancer Center in Oklahoma City
- Proton Center at M.D. Anderson Cancer Center in Houston
- Proton Therapy Institute at the University of Florida in Jacksonville
- Midwest Proton Radiotherapy Institute at Indiana University

Four other centers are trying to launch proton beam centers, but some have been delayed, in part because of difficulty raising money during the recession, says Leonard Arzt, executive director of the National Association for Proton Therapy. An eighth center in Hampton, VA, is scheduled to open this August.

However, proton beam treatment is controversial. Some policymakers and researchers worry that there has not been the kind of clinical trial validation to assure that proton beam approaches are really better than standard radiation, brachytherapy, CyberKnife, or Image Guided Radiation Therapy (IMRT).

Last September, the National Cancer Institute said in a bulletin that of the estimated 1.47 million Americans who will be diagnosed with cancer in 2009, 60% to 75% will undergo radiation therapy for their disease.

"In select cities around the country, some of these patients who are hoping to improve their odds for a cure and minimize the long-term adverse effects of radiation therapy will be treated with a relatively new form of it called proton therapy.

"Public interest in proton therapy has grown substantially since the FDA approved it in 2001. However, there is concern among members of the medical and research communities that enthusiasm for this promising therapy may be getting ahead of the research.

The NCI paper continued, quoting Kevin Camphausen, MD, chief of NCI's Radiation Oncology Branch, who has referred patients to be evaluated for the treatment when he felt it might work well for their tumor type. "Proton therapy has wonderful potential as a treatment for some cancers. But I don't think its use should become widespread until we can validate where it's needed, and where it has the greatest potential benefit for patients."

Added Norman Coleman, MD, associate director of the Radiation Research Program (RRP) at NCI, "Theoretically, proton beams are much more exact than x-rays. On the computer screen, the calculations look great, and the enthusiasm is understandable. But is that what's really happening in the patient?"

"Should I get proton therapy?" is a question that my patients often ask me, and you may be thinking about it right now. The short answer is that "it depends." Only you and your oncologist should be making this decision.

Before deciding IF you should receive proton therapy, you need to know WHAT it is. Proton Therapy Center at M. D. Anderson, we often need to use many different beams to cover the tumor and this can result in more radiation exposure to normal tissues. This is where proton therapy has the edge. Protons deposit most of their dose at the tumor and, more importantly, stop traveling after they hit the tumor. This reduces the radiation dose beyond the tumor, allows the use of fewer beams and provides greater sparing of normal tissue.

Proton treatment requires sophisticated machinery and expert professionals to deliver it. The synchrotron will accelerate protons to almost the speed of light for maximal penetration. Inside the synchrotron they may travel 300,000 miles, which is equivalent to circling the earth 12-13 times. The protons are then fed to the treatment gantry, which is a massive 190-ton device that directs the proton beam before it enters the patient. Despite its large size (over 40 feet in diameter), the gantries have a precision of 1mm. We also have a highly trained, dedicated group of professionals who operate and maintain the Proton Therapy Center to ensure that everything works to its best level.

Proton therapy is currently available in only seven centers in North America. M. D. Anderson has one of the largest and technically advanced centers in the world. We have four treatment rooms, including one of the only centers with spot-scanning (a.k.a. pencil-beam scanning) capabilities.

The first patient was treated with proton therapy at M. D. Anderson on May 4, 2006, and since then we have treated more than 1,700 patients. We have a lot of experience treating patients with lung cancer, esophageal cancer, brain tumors and prostate cancer, as well as various other tumor sites. Also, we're one of the most active centers in the world for treating children with proton therapy.

Since the Proton Therapy Center is part of M. D. Anderson Cancer Center, we can provide our patients not only with outstanding proton therapy but also outstanding cancer therapy.

So, should you receive proton therapy? Please consult with your radiation oncologist or check out our website for more information.

(ARA) - Hearing the word cancer from a doctor can change a patient's life. While cancer treatments such as radiation therapy save millions of lives each year, those who undergo these widely used therapies can suffer serious short- and long-term side effects.

For many cancer patients, there is an alternative to radiation therapy - one that has few, if any side effects and allows most patients to go on with their day-to-day activities and lead a normal life while undergoing treatment. Proton therapy has been successfully used to treat cancer for decades, but because there are only a handful of centers in the U.S. offering the therapy, many doctors remain unaware of the treatment and its benefits

Richard Gordon of Oklahoma was one of the 12 million people diagnosed with cancer last year. He also was one of more than 6,000 patients treated last year with proton therapy.

At 59, Gordon was vital, healthy and did all the things the experts said he should do - eat right, exercise often, maintain a good weight and avoid smoking - yet a routine checkup discovered aggressive prostate cancer. At the advice of his physician, Gordon underwent a prostatectomy and then began exploring post-operative treatment options. The aggressiveness of his cancer prompted doctors to advise him to have radiation.

"After learning about the permanent damage to my healthy tissue and other side effects, I decided not to pursue radiation therapy," says Gordon.

As Gordon was weighing his treatment options, he noticed a large medical building under construction near his office in Oklahoma City. After learning that it was the new ProCure Proton Therapy Center, Gordon researched proton therapy and decided he wanted to learn more. After meeting with the Center's manager of patient services he decided to pursue proton therapy.

Gordon underwent treatment at the ProCure Proton Therapy Center in Oklahoma City, the sixth center to open in the U.S. Plans to build more than a dozen other proton centers have been announced, including a ProCure center in Illinois that will be treating patients before the end of the year.

Studies have shown proton therapy to be effective in treating a number of types of cancer, including prostate, brain, head and neck, central nervous system and lung, as well as those that cannot be completely removed by surgery. It is particularly useful in treating childhood cancers because proton therapy causes less damage to young, healthy, developing tissue than other forms of radiation therapy.

Like standard radiation therapy that uses X-rays radiation, proton therapy kills cancer tumor cells by preventing them from dividing and growing. Unlike X-ray radiation, protons deposit most of their energy directly in the cancer tumor, meaning patients can receive higher, more effective doses, with less damage to healthy tissues near the tumor.

"My treatments would start at 8 a.m. I would be done by 8:30 and in the office, going about my regular day by 9," Gordon says. "I felt like a healthy person while I was going through proton therapy."

Beams of heavy ions can target hard-to-reach tumors with great accuracy and with minimal damage to surrounding tissues. (Heidelberg Ion-Beam Therapy Center)

For certain kinds of cancer, the most effective therapy does not use x-rays or gamma rays but beams of ions, the electrically charged cores of atoms, including hydrogen ions (protons) and heavier ions such as carbon and neon.

The world’s foremost experts in this unique medical therapy are meeting at a workshop for Ion Beams in Biology and Medicine on October 26-29 at the Claremont Hotel in Oakland, Calif., sponsored by Berkeley Lab’s Accelerator and Fusion Research Division. It’s the 13th gathering of this international workshop, but the first to be held in the United States.

This is a curious fact in itself, considering that the entire field of ion beam therapy and nuclear medicine was developed principally at Berkeley Lab and arose from the early work of Ernest Lawrence, inventor of the cyclotron, and his physician brother, John. Late in 1936, John Lawrence performed the first cancer therapy with radioactive isotopes artificially produced with a particle accelerator; he later investigated using charged particle beams directly for therapy.

Today, beams of protons or heavier ions can be accelerated to precisely calculated energies and can be accurately targeted to tumors, which may be large or very small and may be dangerously shaped or positioned – surrounding the spinal cord, for example, or close to the optic nerve, or in the center of the brain. Due to their physical and biological properties, ion beams can target the tumor cells with precision, while minimizing damage to surrounding tissues. Thus ion-beam therapy is a better choice for treatment to avoid high-risk surgery, widespread damage from other forms of radiation therapy like x-rays, or the debilitating effects of drugs that may unnecessarily affect the body’s normal tissues.

The rise of ion-beam therapy

In the years following World War II, Berkeley Lab launched major programs of ion-beam research. In 1946 Ernest Lawrence asked Robert Wilson, a former student of his then at Harvard, to make certain calculations of radiation shielding, which led Wilson to conclude that the Bragg peak (the maximum energy deposition) of beams of hadrons – strongly interacting particles including protons – made them promising for radiation therapy. Properly targeted, hadron beams could put virtually all their energy into the tumor, destroying it while limiting the damage to other tissues characteristic of x-ray therapy.

Protons were first tested as a cancer therapy for humans at Berkeley Lab beginning in 1954, using the 184-Inch Cyclotron as the source of the proton beams. Wilson, who later founded the Fermi National Accelerator Laboratory in Illinois, helped establish the first hospital-based proton therapy center in the United States at the Loma Linda University Medical Center in Southern California. World-wide, some 70,000 patients have now been treated with proton beams.

Berkeley Lab’s Cornelius “Toby” Tobias had pioneered the biomedical applications of proton beams in 1948, and in 1955 he worked with physicians to begin treating human patients, extending medical therapy to the use of helium ions. In 1957 Berkeley Lab’s Heavy Ion Linear Accelerator (HILAC) was built, and Tobias and others started investigating the use of heavier ion beams in cancer therapy.

In the 1970s, heavy ions from the HILAC were piped into the Bevatron proton accelerator to form the Bevalac. With the Bevalac, radiation oncologist Dr. Joseph Castro of the University of California, San Francisco led long-term clinical trials that established the biomedical properties of carbon, neon, silicon, and argon beams, resulting in the first evidence that heavy charged-ion beams could be safely and effectively used to treat cancer.

Until the Bevatron was shut down in 1993, almost 3,000 patients, including some 1,400 cancer patients, were treated at the 184-Inch Cyclotron and the Bevalac. Over time it became evident that heavier beams of neon and carbon were the most effective at treating certain types of cancers that were not responsive to conventional therapies or involved greater radiation doses to surrounding normal tissues.

These included prostate cancer and cancers of the head and neck, such as salivary gland tumors. Long-term results from the clinical trial showed that the effect of ion beams on tumors was due to precise physical dose distributions, and also to unique biological effectiveness. Still heavier ion beams such as silicon and argon, however, were not as beneficial as beams of neon and carbon.

Although many proposals for medical accelerator facilities were put forth by Berkeley Lab researchers and their colleagues in the late 1980s and early 1990s, a combination of economic and social factors prevented their realization. The world’s first dedicated carbon-ion medical facility, although inspired by the work at Berkeley Lab, was not built in California but in Japan.

The success of heavy-ion therapy overseas

HIMAC, the Heavy Ion Medical Accelerator in Chiba, Japan, began the first full clinical trials with carbon-ion therapy in 1994. In Japan, HIMAC was joined by two more carbon-beam facilities: one in Hyogo in 2002, and a second at Gunma University in 2010. The Japanese plan to build additional, more compact carbon-ion accelerators using the Gunma machine with its smaller footprint as a prototype.

In Germany, the Heidelberg Ion-Beam Therapy (HIT) Center opened in 2009; clinical studies of over 400 patients in Germany had previously documented a cure rate of up to 90 percent using carbon-ion beams. In Italy, France, Austria, and China, ion-beam centers are under construction. Over 7,000 patients have been treated by today’s heavy-ion facilities.

Although it’s estimated that some 4,500 patients a year in the greater Bay Area could benefit from ion-beam therapy with either protons or carbon ions, there are no proton- or carbon-ion-beam facilities in Northern California, and no carbon-ion facilities at all in the U.S. While major proton facilities have operated in Loma Linda, Calif. and Boston, Mass., only recently has the U.S. begun to catch up with the rest of the world in building additional proton-beam facilities.

No doubt the high cost of these facilities, which require particle accelerators and elaborate gantry mechanisms to steer and precisely aim the ion beams, is an important factor in the slow adoption of ion-beam therapy in the United States. Costs rapidly come down with experience, however; in Japan the new Gunma facility cost a third as much as the HIMAC facility on which it was modeled.

Another factor is insurance. In the U.S., proton therapy is now covered by Medicare and most health insurance companies, but at present carbon-ion therapy is considered experimental in this country, while in countries like Germany and Japan health care providers cover carbon-ion therapy.

The October workshop on Ion Beams in Biology and Medicine promises lively debate on these questions. Along with presentations on accelerators, beams, gantries, and detectors, and discussions of the biological and medical effects of different kinds of particle beams on different tissues and organs – including spirited comparisons of proton-beam versus carbon-beam therapy – the attendees will discuss the challenge of bringing heavy-ion therapy back to the U.S.

To discuss the relative merits of protons and carbon ions in cancer therapy, Joseph Castro and other former colleagues of the late Professor Tobias, including Eleanor Blakely of the Life Sciences Division founded by John Lawrence, will be joined by experts from other institutions including physicians Hirohiko Tsujii of Japan’s National Institute of Radiological Sciences, Stephanie Combs of the Heidelberg Ion-Beam Therapy Center, and Herman Suit of Massachusetts General Hospital. Their discussion will make use of data from clinical trials, including those at Berkeley Lab going back to the 1970s.

Obstacles to reintroducing heavy-ion therapy to the U.S. will be addressed in a roundtable discussion by Combs, Suit, Tsujii, and others, including William Chu of the Accelerator and Fusion Research Division, a long-time colleague of Tobias’s. The roundtable will be chaired by Dr. Mack Roach, Chairman of the Department of Radiation Oncology at the University of California, San Francisco, and Richard Hoppe, Chairman of the Department of Radiation Oncology of Stanford University.

Among the many other distinguished participants at the workshop, former Berkeley Lab Director Andrew Sessler will have a unique perspective on the successes and set-backs of ion-beam therapy in the U.S. Sessler was director from 1973 to 1980 and is currently a staff scientist in the Accelerator and Fusion Research Division, which he founded in 1977. Sessler greatly expanded the Lab’s mission from an exclusive focus on high-energy physics to programs in Earth sciences, energy efficiency, new energy sources, and a renewed and broadened interest in health and medicine. His support for the heavy-ion beam pioneers was critical to the success of these therapies around the world.

ScienceDaily (Oct. 19, 2010) — Proton beam therapy is safe and effective and may be superior to other conventional treatments for Stage I inoperable non-small cell lung cancer (NSCLC) patients, according to a study in the October issue of the International Journal of Radiation Oncology * Biology * Physics, the official journal of the American Society for Radiation Oncology (ASTRO).

Lung cancer is the number one cause of cancer death for men and women, according to the American Cancer Society. The standard treatment for early-stage lung cancer is surgery to remove all or part of the lung, but for patients with inoperable lung cancer, radiation is commonly used for treatment.

Researchers in Japan sought to determine if proton beam therapy was a good treatment option for patients with inoperable NSCLC versus conventional external beam radiation therapy and stereotactic body radiation therapy, which is a specialized type of external beam radiation therapy that uses focused radiation beams to target a well-defined tumor and relies on detailed imaging, computerized three-dimensional treatment planning and precise treatment setup to deliver the radiation dose with extreme accuracy.

Patients were treated with proton beam therapy from November 2001 to July 2008 with different doses given to peripherally located tumors and centrally located tumors. The two-year progression-free survival rates for those doses were 88.7 percent and 97 percent, respectively. The survival rate for stereotactic body radiotherapy is 54.7 percent at two years and the survival rates for conventional radiotherapy range from 6 percent to 31.4 percent at five years.

"Proton beam therapy is safe and effective, if not superior to other nonsurgical modalities, for treating patients with inoperable Stage I NSCLC," Hidetsugu Nakayama, M.D., Ph.D., lead author of the study and a physician at the Proton Medical Research Center in Tennoudai, Tsukuba, Ikbaraki, Japan, said. "The randomized clinical trial that compares proton beam therapy with stereotactic body radiotherapy is needed to clarify survival benefit."

ScienceDaily (Sep. 22, 2008) — Patients who are treated with proton therapy (a specialized type of external beam radiation therapy using protons rather than X-rays to treat cancer) decreases the risk of patients developing a secondary cancer by two-fold, compared to being treated with standard photon radiation treatment, according to a first-of-its-kind study.

This study contradicts recent theories that have suggested that proton radiation might actually increase — instead of decrease — the incidence of secondary cancers because of what is called scatter radiation. When proton radiation is delivered, neutrons are produced by nuclear interactions and are therefore scattered as a result.

"This study could have a substantial impact on the care of patients," Nancy Tarbell, M.D., senior author of the study and a radiation oncologist at the Massachusetts General Hospital in Boston, said. "Since cancer patients are surviving for longer periods of time, side effects of therapy are becoming increasingly important for doctors to consider when developing treatment plans. Since this is a retrospective study, however, we will need additional studies to further prove this hypothesis."

Photon radiation is the standard external beam radiation therapy treatment, while proton radiation is a more targeted form of external beam radiation which delivers less radiation to bordering normal structures. During external beam radiation therapy, a beam of radiation is directed through the skin to the cancer and the immediate surrounding area in order to destroy the main tumor and any nearby cancer cells.

The retrospective cohort study matched 503 patients who underwent Harvard Cyclotron proton radiation treatment with 1,591 patients treated with photon radiation therapy from the Surveillance, Epidemiology, and End Results (SEER) cancer registry from 1974 to 2001. According to the study, 6.4 percent of patients who underwent proton therapy developed a secondary cancer while 12.8 percent of patients who had photon treatment developed another type of cancer.

PHOENIX & ROCHESTER, Minn.--(BUSINESS WIRE)--Mayo Clinic today announced plans to establish the Mayo Clinic Proton Beam Therapy Program as part of Mayo’s national three-site cancer center in Minnesota, Arizona and Florida. The new program will employ intensity modulated proton therapy — based on pencil beam scanning — which is a more precise form of proton therapy treatment that allows greater control over radiation doses, shorter treatment times and fewer side effects. It is also believed to be more cost effective in selected patients.

As part of the integrated program, Mayo Clinic will build facilities on Mayo’s campuses in Minnesota and Arizona.

Of the existing proton therapy centers in the United States, few use pencil beam scanning exclusively. Pencil beam scanning uses a narrower beam than a traditional proton beam. All eight treatment rooms at Mayo Clinic’s two new facilities will feature this advanced technology.

“We are enthusiastically moving forward with this program because we believe it offers additional, innovative options for cancer patients,” says John Noseworthy, M.D., Mayo Clinic president and CEO. “As with all treatments offered to our patients, we’ll include the proton beam therapy program in our teamwork approach of integrated care. We look forward to collaborating with other health care providers to maximize the full potential of the pencil beam scanning proton program for patients at Mayo and beyond.”

The Arizona proton beam therapy program will be located east of the Mayo Clinic Specialty Building on the Phoenix campus.

“This is a very important addition to our campus and will significantly enhance the care we are able to provide to our patients,” says Victor Trastek, M.D., vice president and CEO of Mayo Clinic in Arizona.

The experience at other organizations has shown that pencil beam scanning is an advancement over traditional radiotherapy to treat some cancers because its beam is targeted only to the tumor, sparing surrounding tissue, and can therefore be used at higher therapeutic doses and with fewer side effects. In contrast, a traditional X-ray beam passes through tumors, irradiating everything in its path. Pencil beam scanning also uses a beam that is much smaller than traditional proton treatments, allowing physicians to more accurately and safely destroy only tumor tissue.

“The benefit to children is especially clear,” says Robert Foote, M.D., chair of Mayo Clinic’s Department of Radiation Oncology in Rochester. “Children with cancer suffer the greatest long-term harm from conventional X-ray therapy since their organs are still developing.”

The technology also will help advance the science of pencil beam scanning, according to Dr. Foote. “All patients receiving proton therapy treatments will be part of a patient registry that will allow Mayo Clinic to track these patients prospectively into the future, determine which patients gain the most benefit and incorporate these findings into new care models and services for cancer patients.”

Mayo Clinic physicians and scientists will use the pencil beam scanning in treating some head and neck, breast, gastrointestinal, lung, spine and prostate cancers, and tumors in or near the eye.

“Protons administer a smaller dose to normal tissues for a given tumor dose than conventional radiotherapy,” says Steven Schild, M.D., chair of the Department of Radiation Oncology at Mayo Clinic in Arizona. “Our proton beam therapy program teams will work in concert to optimize patient care.”

The design and construction of both facilities is expected to begin almost simultaneously. The facility in Minnesota will be located in downtown Rochester just northeast of Rochester Methodist Hospital (corner of Second Street Northwest and First Avenue Northwest). The first treatment rooms are expected to be open by late 2014 or early 2015, and the remaining rooms will be open between six and 12 months later.

During the building phase of each project, a total of 500 construction jobs will be created. When fully operational, the two proton beam programs will employ more than 250 new staff members, including 19 physicians and 19 physicists.

The proton beam therapy program will be fully integrated into Mayo Clinic’s three-site cancer center in Minnesota, Arizona and Florida. More than 20,000 patients receive cancer care at Mayo Clinic each year.

“Mayo Clinic has a long-standing commitment of providing the highest quality of care to patients as a destination cancer center,” says Robert Diasio, M.D., director of Mayo Clinic Cancer Center in Minnesota, Arizona and Florida. “Translating new discoveries to the patient is an essential part of Mayo’s mission. We believe additional benefits of proton beam therapy will include research opportunities that will help advance new therapies for future generations.”

The total capital expenditures for a four-room treatment facility in Rochester will be approximately $188 million and a similar four-room treatment center in Arizona will be $182 million. Funding for the projects is allocated from Mayo’s capital budget and benefactor support.

Rafael Fonseca, M.D., deputy director of Mayo Clinic Cancer Center and a consultant in the departments of Hematology and Oncology, adds: “Patients trust Mayo Clinic to offer treatment solutions with the best outcomes and highest degree of safety. Adoption of proton therapies will set a model of cancer care and allow Mayo Clinic to lessen the burden of cancer on society.”

Proton beam therapy is one form of charged particle cancer therapy. There are other forms that utilize heavier charged particles, such as carbon ions, that share the same dose distribution advantages as protons, but have been shown to be as much as three times more effective in destroying cancer cells as proton therapy. Even as Mayo Clinic develops its Proton Beam Therapy Program, it will continue to evaluate advances in the science and technology of radiation therapy using heavy charged particles to improve cancer care for patients.

Study: Proton treatment for prostate cancer results in few complications

Early data from a study at the University of Florida has found that men under age 55 whose prostate cancer has been treated with proton therapy report that they have few side effects.

In the first 18 months after treatment, they reported high satisfaction for "quality of life" indicators such as sexual and urinary function.

Although erectile dysfunction after treatment can occur, complete impotence was rare and few were dissatisfied with their treatment choice. The results were reported by Dr. Bradford Hoppe, a radiation oncologist at the UF Proton Therapy Institute, during the 52nd Annual Meeting of the American Society for Radiation Oncology.

Proton therapy has been touted as more precise than conventional radiation and some proponents say that it is less likely to lead to complications because the proton beams are targeted.

Conventional radiation uses X-rays, which release energy continuously while moving through the body to the tumor and out the other side. Doctors use advanced computer and imaging techniques to target tumors with high accuracy, but some collateral damage is unavoidable.

Also, X-rays lose power as they penetrate tissues, so they deliver their highest dose at entry.

By contrast, protons can be directed to stop at a tumor, releasing their highest burst of radiation at the site. They don't plow through to the other side, avoiding what doctors call the "exit dose" from X-rays.

Although proton therapy is considered ideal for hard-to-reach tumors in the brain, head and neck, prostate and lung as well as sarcomas, lymphomas and childhood cancers, the treatment is most often used for prostate-cancer patients, who are searching for options that reduce the risk of complications.

Complications can include impotence and incontinence.

But proton therapy is expensive for hospitals and for patients. It typically costs $100 million to build a proton treatment center and treatment may be $20,000 more expensive than conventional radiation treatments. That's why the medical community is still debating whether the expense is worth it .

A 2007 study from the Journal of Clinical Oncology compared proton-beam therapy to a common form of radiation therapy on prostate-cancer patients. The study found that, for a 70-year-old man, the proton-therapy treatment cost $63,511, compared with $36,808 for the more common radiation therapy.

And, compared to the cost of the technology, the benefit of using proton therapy on prostate-cancer patients was marginal, the study concluded.

That's why researchers at UF are studying how effective the therapy is at reducing complications.

At UF, where the patients were all treated at the UF Proton Therapy Institute, the clinical study includes 98 men with low-, intermediate-, and high-risk prostate cancer and who are 55 years old or younger. Patients were evaluated pre-treatment and post-treatment at six month intervals. Rates of reported side effects varied at the six-, 12- and 18-month intervals.

Eighteen months after treatment, the study found:

•21 percent of patients experienced mild urinary side effects that were treated with prescription medication

•3 percent experienced mild gastrointestinal side effects that were treated with prescription medication

•No patients experienced permanent incontinence

•No patients experienced significant rectal side effects

•94 percent of those who did not receive androgen deprivation therapy were sexually active

Proton therapy center chain Procure Treatment Centers Inc. and the Seattle Cancer Care Alliance said Tuesday they've broken ground on what could become the United States' 11th working proton therapy center.

The $160 million, 60,000 square-foot center, dubbed the SCCA Proton Therapy, A ProCure Center, is set to open on the campus of Northwest Hospital & Medical Center in early 2013.

It will be the Pacific Northwest's first such center. Currently, the nearest location for the high-tech cancer treatment is at Loma Linda University Medical Center in southern California.

Although the roots of the technology go back to shortly after World War II, the first center to treat patients, Loma Linda, opened in 1990.

Because of the expense involved in buying and housing a proton-accelerating cyclotron or synchrotron, few centers have been built. There are only nine centers operating in the United States and around 21 worldwide.

The center will be New York-based ProCure's fourth and one of two it currently has under construction. A $162 million center in Somerset, N.J. is scheduled to open in April of next year. ProCure is also in the preliminary stages of developing a two-room center in Michigan with William Beaumont Hospitals and another center with Boca Raton Radiation Oncology Associates in south Florida.

Other proton therapy centers being built include the $65 million McLaren Proton Therapy Center in Flint, Mich., the $119 million ProVision Trust Proton Therapy Center in Knoxville and the $185 million Scripps Health center in San Diego County.

The new Seattle center features one gantry room, two inclined beam rooms and one fixed beam room, following the model held by ProCure's two other centers in Oklahoma City and Warrenville, Ill. Its cyclotron was developed by Belgian firm, Ion Beam Applications S.A.

The cost of the center, financed by a mix of cash and debt, includes land, building costs, equipment and working capital, Opila said.

ProCure's partner, the 11-year-old nonprofit Seattle Cancer Care Alliance, is a cancer research and treatment center owned by Fred Hutchinson Cancer Research Center, University of Washington Medicine and Seattle Children's.

The SCCA had earlier scrapped its 2006 plans to build a $120 million proton therapy facility with Proton Cancer Centers of America LLC., then affiliated with Hitachi America Ltd. That center would have opened in 2010.

Around 70,000 people in the Pacific Northwest were diagnosed with cancer in 2010, according to American Cancer Society figures provided by ProCure. The group believes at least 12,600 of these patients could be candidates for proton therapy.

The combination of high-dose proton therapy with concurrent chemotherapy improved non-hematologic acute toxicity and late acute toxicity in patients with stage III non–small cell lung cancer, according to a study.

Researchers said median survival time in the prospective phase 2 study was 29.4 months compared with the 21.6 months reported in the Radiation Therapy Oncology Group (RTOG-0117) trial.

In the study, Chang and colleagues recruited 44 patients with unresectable or medically inoperable stage III disease from 2006 to 2009. Patients were assigned to 74 Gy proton therapy administered once daily in 2 Gy fractions 5 days per week along with concurrent carboplatin and paclitaxel.

Patients were evaluated at least once every week during treatment; at 6 weeks after completing proton therapy; every 3 months for the first 2 years after finishing treatment; and every 6 months thereafter. Median follow-up was 19.7 months.

No patient experienced grade-5 toxicity and only five patients (11.4%) developed chemotherapy-related grade-4 toxicities — two instances of weight loss and three cases of hemoglobin.

The most common grade-3 adverse events were dermatitis (11.4%) and esophagitis (11.4%). Additionally, there was one case of grade-3 pneumonitis and one case of grade-3 pulmonary/pleural fistula.

At 1 year, OS was 86% and PFS was 63%. Nine (20.5%) patients recurred within the treated area, but only four (9.1%) of those patients had isolated local failure. Four other patients had first recurrence in regional lymph nodes, but only one developed isolated regional recurrence. Distant metastasis was the most common pattern of failure (43.2%).

CLEVELAND — If all goes as planned come 2014, Northeast Ohio residents will have ready access to the latest in radiation therapy treatment for cancer.

On Tuesday, University Hospitals Seidman Cancer Center announced it will open Northeast Ohio's first proton therapy center, a $30 million investment that will be a mix of capital, bonds and philanthropy.

The treatment delivers radiation to hard-to-reach cancer tumors more accurately and efficiently than conventional radiation therapy, and with fewer toxicity and harmful side effects.

Proton therapy uses a powerful beam of protons that targets and matches treatment to the shape of a tumor. As much as 50 to 70 percent more normal tissue surrounding a cancerous tumor remains untouched with proton therapy than with traditional radiation therapy.

Proton therapy is used to treat malignancies such as certain brain, head and neck and pelvic cancers and some prostate cancers. Seidman's proton therapy center is expected to treat between 300-400 patients each year.

Currently there are only nine centers in the country.

"The small number of existing units are used quite a bit for pediatric cancers in certain locations and some adult cancers that are hard to reach," said Seidman President Nathan Levitan.

Ongoing research is trying to determine if proton therapy is effective for breast, liver and lung cancers. Studies are also trying to ascertain whether it is best to use proton therapy alone or in combination with conventional radiation therapy.

"None of these questions are answered yet," Levitan said. "We do expect that by 2014, when we have our unit up and running, more will be known."

About half of all cancer patients receive radiation as part of their treatment, said Dr. Mitch Machtay, chairman of radiation oncology at UH Case Medical Center and Case Western Reserve University School of Medicine.

Proton therapy isn't the automatic best choice for every cancer patient, he said.

"We have great technology and radiation without having protons," he said. "They don't provide an added benefit for everyone.

Physicians at Seidman will look to use proton therapy when other types of radiation aren't able to completely do the job.

"One -- if not the -- highest priority will be children, adolescents, young adults with cancer who are at higher risk for toxicities," Machtay said.

For children and young adults, whose bones, muscles and organs are still growing, radiation exposure is especially harmful.

"It's even more important in children to get the radiation to conform precisely to the tumor and have minimal radiation to other body parts," Machtay said.

That means fewer side effects, which can be mild (such as sunburn, some fatigue, a little bit of weakness) or extreme (such as total disability or necrosis, the death of living tissue). "We're not going to be happy until we can cure every tumor we treat without causing side effects," Machtay said. "Unfortunately we're not there yet."

One of the reasons that more hospitals and cancer centers don't have proton therapy centers is the massive costs associated with them. Most of the current centers cost around $150 million, the biggest chunk of expenses coming from the equipment and the space needed to house it.

Seidman's center will be housed in one room, using equipment that is much smaller in size but with the same capabilities as the larger systems.

UH and Still River Systems, a Massachusetts-based company started in 2004, have completed an agreement to install the Monarch 250. It's a smaller, more compact proton therapy system that is awaiting Food and Drug Administration approval.

The collaboration between UH and Still Rivers Systems goes back several years.

"We've been working on this process for quite some time," said Lionel Bouchet, the company's senior director of product management. "The approach we're offering is much more cost-effective.

"We anticipate working towards formal filing [with the FDA] within the year," he said. "What it means is that our system will be made more widely available."

At Seidman, work is scheduled to begin in early 2012 on the vault that will contain the unit. The location is yet to be determined. Installation will take place in 2013 and the center will open in 2014.

LOMA LINDA - Loma Linda University Medical Center officials announced "phenomenal" results from a five-year study of 50 women with early stage cancer who were treated with a beam of protons.
The lack of side-effects from proton beam therapy and the few cases of recurring cancer is showing that breast cancer is another appropriate target for proton therapy, said Dr. Mark Reeves, director of the Loma Linda University Cancer Center, at a news conference Tuesday.

Another, more expansive, clinical trial is under way, officials said.

The briefing in front of Loma Linda University Medical Center was to announce the results of the clinical trial, which will published in an upcoming issue of the peer-reviewed scientific journal "Clinical Breast Cancer."

Reeves said that the study showed "incredible" outcomes for participants and a "phenomenal" lack of side-effects for women who were treated as long as seven years ago.

The study involved women who were diagnosed with early (stage one) cancer and who had no signs that the cancer has spread to other areas, said Dr. David Bush, vice-chairman of the LLUMC Department of Radiation Medicine and one of the study's principal investigators.

In the study, the proton therapy was delivered after the cancer was surgically removed.

Although the medical standard is to treat the whole breast with radiation after surgery, in the clinical trial, protons were delivered just to the cancer site.

This allowed the treatment period to be compressed from about seven weeks to two weeks, Reeves said.

And it exposed a smaller area to radiation, Bush said. Radiotherapy for cancer has been shown to increase heart attack risks, and can lead to lung infections and broken ribs, Bush said.

Proton radiation, in contrast to X-rays, does not travel through the body. Its energies can be more narrowly focused - and contained - than other radiotherapy techniques, Bush said.

Twenty years ago, Loma Linda University Medical Center became the first in the country to offer proton beam radiation inside a hospital campus.

In the basement of Loma Linda University Children's Hospital, protons - positively charged subatomic particles - are plucked from hydrogen atoms and accelerated to about 90 percent of the speed of light, Bush said.

High-speed protons are then directed to one of three patient treatment rooms, also in the children's hospital basement.

Originally, proton beams were harnessed to fight brain and eye cancers, Bush said. Over the years, this technology has been applied to other cancers, including those found in the hip, lung and prostate, Bush said.

Vicki Ramirez, one of the women in the study, had experienced heart problems since her teenage years.

Her cardiologist recommended she undergo a mastectomy, to avoid the risk of heart damage due to radiation exposure.

"That was never an option," she said.

She had a partial mastectomy and then during her lunch breaks, two weeks of proton therapy.

Ramirez said her only side effect from the radiation was a mild tan on the breast following treatment.

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